JEFFERSON CITY - Kirby Turnerís job is to heal the stateís poor, disabled and vulnerable.

Don Shrubshell photos

From left, Keith Schafer, director of the Missouri Department of Mental Health, Jane Drummond, director of the Missouri Department of Health and Senior Services, Deborah Scott, director of the Missouri Department of Social Services, and George Oestreich, deputy division director of the Missouri Department of Social Services and Division of Medical Services, give testimony on Wednesday concerning the proposed changes to the stateís Medicaid program. Executive departments will play a significant role in determining specific details of Missouri HealthNet.
Below,
Rep. Rob Schaaf, R.-St. Joseph, chairs the special committee on health-care facilities on Wednesday in a hearing room at the Missouri Capitol. Members of the health-care industry spoke with members of the special committee appointed by the speaker
of the House.

He also has to deal with some literal headaches.

Turner works at a Poplar Bluff clinic that takes in patients on the Medicaid program, a state-federal partnership designed to provide health care for the poor and disabled.

From his experience, Turner has seen people so poor they cannot afford aspirin. But at the same time, he has witnessed abuses of Medicaid in which a patient came to the clinicís emergency room at 3 a.m. to get a bottle of aspirin at Medicaidís expense.

"Thatís an example of a state providing the wrong incentive," Turner said.

Turner acknowledged the example was unusual. But he said it showed the system encourages poor people to pursue costly options at the stateís expense.

"Of course they were poor," Turner continued. "But I donít think we need to make poor as an excuse. That didnít mean she is not knowledgeable to utilize a system wisely if the right incentives were in place."

After cutting about 100,000 people off the Medicaid rolls two years ago, Gov. Matt Blunt and the General Assembly are trying to change the system to encourage people to live healthy, and thus cost the system less.

Blunt calls the new plan "MO HealthNet."

MO HealthNet, in theory, seeks to cajole recipients into pursuing a healthy lifestyle - a path meant to stop costly hospitalizations before they start. It also seeks to provide Medicaid recipients with more personalized and monitored care.

Why fewer qualify
When rules for Medicaid changed two years ago, about 100,000 people lost eligibility. Before, anyone at or below the federal poverty level was eligible; the new policy dropped that to 85 percent of the poverty level.

Source: Department of Social Services

Lora Wegman graphic

Critics of MO HealthNet say it does little to help those who were cut from the rolls in 2005. They also wonder whether the preventative focus can better the lives of 850,000 of the stateís most vulnerable citizens without making it more costly and bureaucratic.

Sharon Feltman, director of policy and communications for the Missouri Association of Social Welfare, said the new plan doesnít restore coverage to those who lost it.

Others see the plan as ducking the issue of provider fraud - something critics say costs the system millions of dollars.

"PREVENTION AND WELLNESS"

MO HealthNet is about redirecting attention from fixing ailments to preventive care, said Sen. Charlie Shields, R-St. Joseph and sponsor of the new plan. Shields believes the existing Medicaid program is not improving peoplesí health. He said people on the program were going to doctors and hospitals dozens of times a year to receive treatment - a pattern he said showed a depreciated quality of life.

"I think you have to look at how much we were spending and what we were getting for that," Shields said. "Quite honestly, Medicaid is not different from the rest of the health-care sector. You heard me say, ĎWeíre No. 2 throughout the industrialized world in health spending per capita, but 36th or 37th in health-care outcomes.í We spend a lot of money as a nation Ö but our populationís not very healthy. And Medicaid is not any different."

Under a self-imposed deadline set by the legislature, Medicaid is set to expire in 2008.

"The old Medicaid was about sickness," Blunt said. "The new HealthNet will be about prevention and wellness."

The concept of preventive care prevails throughout Shieldsí legislation. Itís a concept, he said, that will not only save the state money but also improve the quality of life for the stateís poorest citizens.

"Paying for wellness upfront always saves money," he said.

Under the new plan, a qualified Medicaid recipient will sign up for one of three programs, depending on the recipientís needs. A person with multiple health problems, for example, would sign for a section that provides a more intensive regimen.

One of the planís novel provisions is that every recipient would choose a "health-care advocate," a person who would help a person through the Medicaid process. For example, a Medicaid recipient who has diabetes would tell the advocate about his or her history with the disease.

The advocate would then point the person to programs that balance nutrition and control weight. Such moves, in theory, would prevent a person from getting seriously ill and being hospitalized - which, in turn, would save the state money.

There are questions about whether the advocate model will cost too much and whether the plan would work. There is no requirement that the advocate be a primary care physician; instead, the person is required to be a medically licensed individual practitioner. Because doctors are busy, Shields said that would keep them from also serving as health-care advocates.

James Kimmey, a doctor and president of the Missouri Foundation for Health, said the sheer size of the program could bring additional challenges. Kimmey, who is in charge of a not-for-profit organization brought about by the privatization of Blue Cross/Blue Shield, said advocates could be burdened with work, especially because there are hundreds of thousands of recipients in the Medicaid system.

"Thatís a very good idea in the abstract, and where there have been health-care advocates, theyíve worked very well," Kimmey said. "The question is: Has this legislature thought of the added cost for the advocates program?"

Kimmey said advocates say the maximum caseload that can be effectively managed is 30. That means that under the stateís current caseload, the plan could call for more than 28,000 advocates.

HEALTH INCENTIVES

Another aspect of the bill provides incentives for doctors and patients. Under the plan, doctors would receive higher Medicaid reimbursements if a patient recovers quickly.

The pay-for-performance aspect is - even by Shieldsí admission - not very well defined. A common criticism of the bill is that it is vague and would leave it up to regulatory agencies to fill in the blanks.

"It is a hollow shell of a bill that will allow mean-spirited details to be filled in behind closed doors without public scrutiny," Feltman said.

Shields said it would be impossible to place every detail of HealthNet into a 78-page bill, especially the pay-for-performance component. He said regulatory agencies, as well as an oversight committee that would be created to monitor the program, could do a better job of quantifying how well a doctor does his or her job.

Some fear that paying doctors more for patients who improve quickly will mean that only those with less severe health problems will get treatment. But Shields said that would not happen with proper regulatory oversight.

Reimbursement has been the key issue for physicians who treat Medicaid patients. They argue that without adequate payback from state government, there isnít much incentive for providers to see Medicaid recipients.

The other incentive program is a debit card that would provide points to Medicaid recipients who pursue healthy behaviors. These points could be redeemed for rewards, such as payments for prescription medicine.

Shields said the advocate would tailor the benefit to specific recipients.

"One of the things that weíve heard from advocates for the disabled is we want those benefits very much personalized to the individual," Shields said. "So the advocate plays a role in developing those incentives."

Turner, the Poplar Bluff clinician, said he likes the billís emphasis on wellness and prevention.

"If you diet and exercise and keep your weight under control, you donít get diabetes and hypertension," Turner said. "And itís going to cost the system very much less money because youíre going to need much less care."

In theory, Kimmey said the debit card idea seems like a good plan. But he said he is concerned the preventive care focus could work as a barrier to deliver health care to individuals.

"As we move to having legislation to having actual programs, you have to be very careful that they donít confuse the role of prevention here," Kimmey said. "Prevention is really good in and of itself. People should not be penalized from receiving occupational therapy or some of the things they listed in the bill because they canít or wonít participate in preventative programs."

FRAUD IN THE SYSTEM

Donna Wilson sees Medicaid as a lifeline.

Wilson, a retired factory worker from Foristell, became a diabetic in the 1980s. The disease eventually left her blind and at times confined to wheelchair. She depends on the Medicaid program to provide her with insulin pumps that keep her alive.

Because of her disability, Wilson was spared from the Medicaid cuts two years ago. But Wilson and her husband, Jerry, became involved in another aspect of the Medicaid debate when they tried to focus attention on what they thought was provider fraud.

Jerry Wilson said a company made dozens of charges to Medicare, a federal health-care program for the elderly, and then charged Medicaid for the same health-care services under a different company name.

When the Senate debated Shieldsí bill, an amendment was proposed to deal with Medicaid provider fraud. At first the amendment would have allowed an individual to sue a provider in the event the attorney general couldnít find sufficient evidence of wrongdoing. However, in the end, that provision was removed.

Critics said taking out that option weakened the amendment. But Blunt said in the end, there were enough anti-fraud provisions in the bill.

"It seems to be a compromise between the House and Senate position that clearly strengthens our tools and our ability to go after Medicaid fraud," Blunt said.

Before he was elected to office, Blunt said rooting out "waste and fraud" from the Medicaid system would save the state money. But the governor backed the cuts of recipients first, and the General Assembly is still haggling over the anti-fraud provisions.

"Gov. Blunt started making the cuts first, and then nothing else," Jerry Wilson said. Wilson said he wants a commission to make sure fraudulent providers are caught and punished.

REDUCING THE ROLLS

Blunt and the Republican-controlled legislature reduced the Medicaid rolls two years ago by changing eligibility rules. The state cut the number of people eligible for Medicaid from 100 percent of the federal poverty standard to 85 percent. Thus, a single person had to earn $8,679 or less per year to qualify under the new rules. Before, the person could earn as much as $10,210 and still qualify. This calculation is based on 2007 dollars.

Critics of the new plan note its does not restore these cuts - an inaction that they say fails to rectify a significant public policy problem. Democrats said that people who were cut off the program are still going to get sick and still need health care for their ailments. But when this happens, those people are going to use hospital emergency rooms - an expensive option that ends up being paid with public dollars.

In addition, Democrats said that since Missouri residents were cut off Medicaid in 2005, hundreds of millions federal dollars have gone to other states - such as Massachusetts, which embarked on an ambitious plan to provide protection for the uninsured. Democrats made several unsuccessful attempts to restore some Medicaid cuts during the initial stage of debate.

Republicansí counterargument is that there is a component of the new plan to help people thrown off Medicaid to get health-care coverage through an additional feature in HealthNet known as the premium offset program.

Premium offset would combine state, federal, employee and employer money in an attempt to provide low-income workers with private health insurance. Using that pool of funds - as well as moneys from hospitals - uninsured workers could buy private health insurance plans.

But analysts with the Missouri Budget Project, a group that has been critical of HealthNet, said other statesí premium offset programs have not been well utilized. In Massachusetts, for example, 33,000 people signed up, the most out of all the states offering such programs. In Missouri, of the 100,000 who lost coverage, 30,000 might be covered under the new program, but 70,000 would not.

"Ensuring that working Missourians have access to health coverage is important," said Ruth Ehresman, director of health and budgetary policy at the Missouri Budget Project. "However, the premium offset component of the proposed MO HealthNet program will only be effective if enrollment is high, plans are affordable, employers actively participate and the insurance coverage provided is adequate."

Dave Dillon, a spokesperson for the Missouri Hospital Association, said the billís emphasis on preventive care seems to be the right approach.

"We support the direction that the proposal is going, as it goes for patients to have some responsibility for their own health," Dillon said. "Itís a regular part of medicine to try and give some responsibility for ensuring their own health."

Dillon added that all people who come into hospitals would receive care - as required by law.

Kimmey said the emphasis on prevention and wellness is the right direction to take. But he said it might be hard for people living in rural areas to participate.

"Transportation access can be an issue there," Kimmey said. "But itís also that you might not have enough providers participating in a managed care plan because youíre low on providers anyway to make that feasible."

Now, in the final weeks of the session, the House will have a chance to rework the bill. That effort will be led by Rep. Rob Schaaf, a St. Joseph Republican and doctor.

Turner plans to monitor the situation closely.

"Iím looking forward to it, not that I think itís going to cure all the problems, but I know that health care and the health-care system is terribly broken, and Medicaid in particular," Turner said. "I think this is an opportunity for providers to prove their mettle."